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MED112 CODE/BILL
MED112 CH 11 TRICARE AND CHAMPVA SB
| Question | Answer |
|---|---|
| MED112 CH 11 SB | |
| TRICARE replaced which of the following programs? A. National Health B. CHAMPUS C. Kaiser Permanente D. DOD | B. CHAMPUS |
| Providers may decide to participate on a ____ basis. A. scheduled B. case-by-case C. year-to-year D. month-to-month | B. case-by-case |
| A provider who chooses not to participate in TRICARE may not charge more than ____ of the allowable charge. A. 115% B. 20% C. 105% D. 100% | A. 115% |
| Once authorized, a provider is assigned a ____ and must decide whether to participate. A. contract B. personal identification number C. provider specialty number D. letter of approval | B. personal identification number |
| TRICARE participating providers agree to accept the allowed charge as A. payment in full B. a partial payment C. a one-time courtesy D. installment payments | A. payment in full |
| After enrolling in the TRICARE Prime plan, individuals are assigned a A. Physician's Assistant B. Primary Care Physician C. Primary Care Manager D. Nurse Care Manager | C. Primary Care Manager |
| Which of the following apply to TRICARE in terms of providers? (MAY BE MORE THAN ONE) A. Pays only for services rendered by authorized providers B. Uses regional contractors to certify authorized providers C. Uses both authorized and nonauthorized providers D. Regional contractors certify that authorized providers have met specific education, licensing, and other requirements | A. Pays only for services rendered by authorized providers B. Uses regional contractors to certify authorized providers D. Regional contractors certify that authorized providers have met specific education, licensing, and other requirements |
| The maximum amount TRICARE will pay for a procedure is known as the ________. A. TRICARE fee standard B. TRIMAX C. TRICARE allowed amount D. CHAMPUS Maximum Allowable Charge | D. CHAMPUS Maximum Allowable Charge |
| Which of the following apply to TRICARE? (MAY BE MORE THAN ONE) A. TRICARE does not cover military dependents. B. Military hospitals work with a network of civilian facilities and providers to offer increased access to healthcare. C. TRICARE contracts with civilian facilities and physicians to provide more extensive services to beneficiaries. D. All military treatment facilities, including hospitals and clinics, are part of the TRICARE system. | B. Military hospitals work with a network of civilian facilities and providers to offer increased access to healthcare. C. TRICARE contracts with civilian facilities and physicians to provide more extensive services to beneficiaries. D. All military treatment facilities, including hospitals and clinics, are part of the TRICARE system. |
| Which of the following statements apply to providers authorized to treat TRICARE patients? (MAY BE MORE THAN ONE) A. Authorized providers serve patients in one of TRICARE's managed care plans. B. Authorized providers agree to provide care to beneficiaries at contracted rates. C. Authorized providers agree to provide care to beneficiaries at regular rates. D. Authorized providers may also contract to become part of the TRICARE network. | A. Authorized providers serve patients in one of TRICARE's managed care plans. B. Authorized providers agree to provide care to beneficiaries at contracted rates. D. Authorized providers may also contract to become part of the TRICARE network. |
| If a nonparticipating provider bills more than 115 percent to TRICARE, the patient may ________ the excess amount. A. negotiate B. be required to pay C. refuse to pay D. defer | C. refuse to pay |
| Which of the following services are covered under TRICARE Prime? (MAY BE MORE THAN ONE) A. Dental care B. Custodial services C. Women's health and pregnancy D. Cosmetic surgery E. Hospital care | A. Dental care C. Women's health and pregnancy E. Hospital care |
| Which of the following apply to the effect of the Medicare Fee Schedule on TRICARE reimbursement? (MAY BE MORE THAN ONE) A. Providers are responsible for collecting patients' deductibles and their cost-share portions. B. Providers who participate in TRICARE are paid based on the amount in the Medicare Fee Schedule. C. Medical supplies, medical equipment, and ambulance services are not subject to Medicare limits. D. Medical supplies, equipment, and ambulance services are subject to Medicare limits. | A. Providers are responsible for collecting patients' deductibles and their cost-share portions. B. Providers who participate in TRICARE are paid based on the amount in the Medicare Fee Schedule. C. Medical supplies, medical equipment, and ambulance services are not subject to Medicare limits. |
| Which of the following statements apply to providers who choose not to join the TRICARE network? (MAY BE MORE THAN ONE) A. TRICARE is 100 percent responsible for the charges for non-network providers. B. The patient is 100 percent responsible for the charges of an out-of-network provider. C. TRICARE may not pay for services to providers who choose not to join the network. D. Providers who choose not to join the network may still provide care to managed care patients. | B. The patient is 100 percent responsible for the charges of an out-of-network provider. C. TRICARE may not pay for services to providers who choose not to join the network. D. Providers who choose not to join the network may still provide care to managed care patients. |
| Identify which services TRICARE generally does not cover. (MAY BE MORE THAN ONE) A. Unproven procedures B. Diagnostic testing C. X-rays D. Experimental treatment | A. Unproven procedures D. Experimental treatment |
| TRICARE Select is available to people who meet which of the following requirements? (MAY BE MORE THAN ONE) A. Active-duty service members B. Enroll annually C. Verifiable eligibility through DEERS D. Have no pre-existing conditions | B. Enroll annually C. Verifiable eligibility through DEERS |
| Which of the following are true of TRICARE Prime? (MAY BE MORE THAN ONE) A. Enrollees and dependents receive the majority of their healthcare services from military treatment facilities. B. Enrollees receive priority at military treatment facilities. C. TRICARE Prime does not offer preventive care, such as routine physical examinations. D. Offers preventive care | A. Enrollees and dependents receive the majority of their healthcare services from military treatment facilities. B. Enrollees receive priority at military treatment facilities. D. Offers preventive care |
| Which of the following services are covered under TRICARE Prime? (MAY BE MORE THAN ONE) A. Primary care B. Experimental treatment C. Preventive care D. Tests and X-rays E. Cosmetic procedures F. Not medically necessary procedures | A. Primary care C. Preventive care D. Tests and X-rays |
| Which of the following apply to TRICARE for Life? A. Enrollees must submit claims for TRICARE for Life-covered services, even w/ no other health insurance. B. TRICARE for Life enrollees who reach 65 no longer continue to obtain medical services at military hospitals and clinics. C. If the patient has other health insurance, the claim is automatically submitted to TRICARE. D. TRICARE beneficiaries entitled to Medicare Part A are required by law to enroll in Medicare Part B to retain TRICARE benefits. | D. TRICARE beneficiaries entitled to Medicare Part A are required by law to enroll in Medicare Part B to retain TRICARE benefits. |
| Identify which services TRICARE generally does not cover. (MAY BE MORE THAN ONE) A. Diagnostic testing B. Cosmetic surgery C. Medically necessary surgery D. Cosmetic drugs | B. Cosmetic surgery D. Cosmetic drugs |
| The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is the government's health insurance program for the families of veterans with ________ service-related disabilities. A. 25 percent B. no C. 100 percent D. partial | C. 100 percent |
| Identify all of the correct eligible beneficiaries for CHAMPVA. (MAY BE MORE THAN ONE) A. Nondependents of veterans B. Dependents of a veteran who is totally and permanently disabled due to a service-connected injury C. Dependents of a veteran who was totally and permanently disabled due to a service-connected condition at time of death D. Survivors of a veteran who died as a result of a service-related disability | B. Dependents of a veteran who is totally and permanently disabled due to a service-connected injury C. Dependents of a veteran who was totally and permanently disabled due to a service-connected condition at time of death D. Survivors of a veteran who died as a result of a service-related disability |
| What are the steps taken by the provider's office when they receive the CHAMPVA Authorization Card from the beneficiary? (MAY BE MORE THAN ONE) A. Keep the card to return to the patient at a later date B. Check the card to determine eligibility C. Photocopy or scan the front and back of the card D. Keep the original card and give the beneficiary a copy | B. Check the card to determine eligibility C. Photocopy or scan the front and back of the card |
| Where do TRICARE Prime enrollees receive the majority of their healthcare services? A. Civilian health facilities B. Private healthcare organizations C. Not-for-profit healthcare organizations D. Military treatment facilities | D. Military treatment facilities |
| Identify the Department of Defense program that offers the opportunity to receive healthcare at a military treatment facility to individuals age 65 and over who are eligible for both Medicare and TRICARE. A. TRICARE for Life B. TRICARE Medicare C. TRICARE Senior Prime D. TRICARE Senior | A. TRICARE for Life |
| Which of the following services are generally excluded by CHAMPVA? (MAY BE MORE THAN ONE) A. CT scan B. Experimental or investigational procedures C. Magnetic resonance imaging (MRI) D. Medically unnecessary services and supplies E. Ambulance services | B. Experimental or investigational procedures D. Medically unnecessary services and supplies |
| ____ is responsible for determining eligibility for the CHAMPVA program. A. the VA B. DEERS C. The State Department D. The Department of Defense | A. the VA |
| Which of these apply to CHAMPVA? (MAY BE MORE THAN ONE) A. Under CHAMPVA, the VA and beneficiary don't share expenses. B. Prior to Veterans Health Care Eligibility Reform Act of 1996, enrollment was not required for veterans. C. Under the program, the Department of Veterans Affairs (VA) and beneficiary share healthcare expenses. D. The Veterans Health Care Eligibility Reform Act of 1996 requires a veteran with 100 % disability be enrolled in the program for benefits. | B. Prior to Veterans Health Care Eligibility Reform Act of 1996, enrollment was not required for veterans. C. Under the program, the Department of Veterans Affairs (VA) and beneficiary share healthcare expenses. D. The Veterans Health Care Eligibility Reform Act of 1996 requires a veteran with 100 % disability be enrolled in the program for benefits. |
| Which of the following apply to preauthorization for procedures for CHAMPVA? (MAY BE MORE THAN ONE) A. Some procedures must be approved in advance. B. CHAMPVA will not pay for some procedures if they have not had a preauthorization. C. It is the responsibility of the patient to obtain preauthorization for some procedures. D. It is the responsibility of the provider to obtain preauthorization for some procedures. Correct Answer: | A. Some procedures must be approved in advance. B. CHAMPVA will not pay for some procedures if they have not had a preauthorization. C. It is the responsibility of the patient to obtain preauthorization for some procedures. |
| Which of the following apply to participating providers for CHAMPVA? (MAY BE MORE THAN ONE) A. CHAMPVA does not set allowable amounts. B. Providers can charge the patient the difference in what CHAMPVA pays and their regular charge. C. Providers agree to accept CHAMPVA payment and the patient's cost-share payment as full payment. D. Providers who treat CHAMPVA patients are prohibited from charging more than the allowable amounts. | C. Providers agree to accept CHAMPVA payment and the patient's cost-share payment as full payment. D. Providers who treat CHAMPVA patients are prohibited from charging more than the allowable amounts. |
| Identify the name of the card each CHAMPVA-eligible beneficiary possesses. A. Treatment Eligibility Card B. CHAMPVA Authorization Card C. VA Card D. TRICARE Authorization Card | B. CHAMPVA Authorization Card |
| Identify the statements that apply to CHAMPVA's cost to patients. (MAY BE MORE THAN ONE) A. In most cases, CHAMPVA pays equivalent to Medicare/TRICARE rates. B. Beneficiaries are not responsible for costs not covered by CHAMPVA. C. CHAMPVA has an outpatient deductible of $50 per person up to $100 per family per calendar year and a cost-share of 25 percent. D. Beneficiaries are responsible for the costs of healthcare services not covered by CHAMPVA. | A. In most cases, CHAMPVA pays equivalent to Medicare/TRICARE rates. C. CHAMPVA has an outpatient deductible of $50 per person up to $100 per family per calendar year and a cost-share of 25 percent. D. Beneficiaries are responsible for the costs of healthcare services not covered by CHAMPVA. |
| Identify all of the outpatient services covered by CHAMPVA. (MAY BE MORE THAN ONE) A. Elective cosmetic procedures B. HIV testing C. Maternity care D. Mental healthcare E. Experimental procedures | B. HIV testing C. Maternity care D. Mental healthcare |
| The two exceptions to CHAMPVA being the secondary payer are which of the following? (MAY BE MORE THAN ONE) A. Private payers B. Third-party payers C. Supplemental policies D. Medicaid | C. Supplemental policies D. Medicaid |
| Which of the following services are generally excluded by CHAMPVA? (MAY BE MORE THAN ONE) A. Custodial care B. Most dental care C. Inpatient surgery D. Diagnostic testing | A. Custodial care B. Most dental care |
| Which of the following apply to CHAMPVA for Life? (MAY BE MORE THAN ONE) A. For services not covered by Medicare, CHAMPVA acts as the secondary payer. B. For services not covered by Medicare, CHAMPVA acts as the primary payer. C. Eligible beneficiaries must be enrolled in Medicare Parts A and B. D. Benefits are payable after payment by Medicare or other third-party payers. | B. For services not covered by Medicare, CHAMPVA acts as the primary payer. C. Eligible beneficiaries must be enrolled in Medicare Parts A and B. D. Benefits are payable after payment by Medicare or other third-party payers. |
| Which of the following are procedures that require preauthorization for CHAMPVA? (MAY BE MORE THAN ONE) A. Mental health and substance abuse services B. Organ and bone marrow transplants C. Office visits D. Hospice services | A. Mental health and substance abuse services B. Organ and bone marrow transplants D. Hospice services |
| Identify the three administration regions for TRICARE. (MAY BE MORE THAN ONE) A. TRICARE South B. International C. TRICARE West D. TRICARE North E. TRICARE East | B. International C. TRICARE West E. TRICARE East |
| Which of the following apply to participating providers for CHAMPVA? (MAY BE MORE THAN ONE) A. For most services, CHAMPVA contracts with providers. B. For mental health treatment, CHAMPVA maintains a list of approved providers. C. For most services, CHAMPVA does not contract with providers. D. Beneficiaries may receive care from providers of their choice as long as those providers are properly licensed to perform services. | B. For mental health treatment, CHAMPVA maintains a list of approved providers. C. For most services, CHAMPVA does not contract with providers. D. Beneficiaries may receive care from providers of their choice as long as those providers are properly licensed to perform services. |
| Which health plans are required to comply with the HIPAA Privacy Policy and procedures for use and disclosure? (MAY BE MORE THAN ONE) A. TRICARE B. MHS C. Work plans D. None of them | A. TRICARE B. MHS |
| Which of the following applies to CHAMPVA's cost to patients? (MAY BE MORE THAN ONE) A. A patient's out-of-pocket costs are subject to a catastrophic cap of $10,000 per calendar year. B. Some services are exempt from the deductible and cost-share requirement. C. A patient's out-of-pocket costs are subject to a catastrophic cap of $3,000 per calendar year. D. Most persons pay an annual deductible and a portion of their healthcare charges. | B. Some services are exempt from the deductible and cost-share requirement. C. A patient's out-of-pocket costs are subject to a catastrophic cap of $3,000 per calendar year. D. Most persons pay an annual deductible and a portion of their healthcare charges. |
| Which of the following apply to fraud and abuse for TRICARE? (MAY BE MORE THAN ONE) A. A qualified independent contractor reviews claims, documentation, and records to ensure services were medically necessary. B. TRICARE providers are not subject to quality and utilization review. C. The DIS works with the Program Integrity Office to identify and prosecute cases of TRICARE fraud. D. TRICARE providers are also subject to a quality and utilization review. | A. A qualified independent contractor reviews claims, documentation, and records to ensure services were medically necessary. C. The DIS works with the Program Integrity Office to identify and prosecute cases of TRICARE fraud. D. TRICARE providers are also subject to a quality and utilization review. |
| When the individual has other health insurance benefits in addition to CHAMPVA, CHAMPVA is almost always the ________ payer. A. secondary B. primary C. only D. first | A. secondary |
| The CHAMPVA claims processing center is centralized in ________. A. San Diego, CA B. New York, NY C. Denver, CO D. Salt Lake City, UT | C. Denver, CO |
| CHAMPVA for Life extends CHAMPVA benefits to spouses or dependents who are age ________ or older. A. sixty-five B. fifty-five C. sixty-six D. seventy-five | A. sixty-five |
| Which of the following apply to filing insurance claims for TRICARE? (MAY BE MORE THAN ONE) A. Individuals use DD Form 2642 when filing claims from nonparticipating providers. B. A copy of the itemized bill from the provider must be attached to the DD Form 2642 when submitting claims. C. Individuals do not use a form when filing claims from nonparticipating providers. D. Individuals do not attach an itemized bill when submitting claims for nonparticipating providers. | A. Individuals use DD Form 2642 when filing claims from nonparticipating providers. B. A copy of the itemized bill from the provider must be attached to the DD Form 2642 when submitting claims. |
| Which of the following apply to how TRICARE must comply with HIPAA? (MAY BE MORE THAN ONE) A. The MHS's Notice of Privacy Practices describes how a patient can access information on how their medical information may be used and disclosed. B. The MHS's Notice of Privacy Practices is posted at the TRICARE website. C. HIPAA regulations are not mandatory. D. The MHS's Notice of Privacy Practices describes how a patient's medical information may be used and disclosed. | A. The MHS's Notice of Privacy Practices describes how a patient can access information on how their medical information may be used and disclosed. B. The MHS's Notice of Privacy Practices is posted at the TRICARE website. D. The MHS's Notice of Privacy Practices describes how a patient's medical information may be used and disclosed. |
| Which agency oversees the fraud and abuse program for TRICARE? A. Government Abuse Office B. Government Fraud Office C. Program Integrity Office D. Oversight Office | C. Program Integrity Office |
| Which of the following apply to the process of filing a claim for CHAMPVA? (MAY BE MORE THAN ONE) A. The information required on a claim form is the same as the information required for TRICARE. B. HIPAA regulations cover the CHAMPVA program. C. The information required on a claim form is not the same as the information required for TRICARE. D. Providers file most CHAMPVA claims and submit them to the central claims center in Denver, Colorado. | A. The information required on a claim form is the same as the information required for TRICARE. B. HIPAA regulations cover the CHAMPVA program. D. Providers file most CHAMPVA claims and submit them to the central claims center in Denver, Colorado. |
| The TRICARE plan that is an HMO and requires a PCM is A. TRICARE Extra. B. TRICARE For Life. C. TRICARE Standard. D. TRICARE Prime. | D. TRICARE Prime |
| A PCP is usually a A. gastroenterologist. B. dentist. C. medical biller. D. medical provider or practice. | D. medical provider or practice. |
| Which of the following receive priority at military treatment facilities? A. TRICARE Prime enrollees B. TRICARE Extra enrollees C. TRICARE Select enrollees D. active-duty service members | D. active-duty service members |
| A TRICARE For Life beneficiary must be at least __________ years old. A. twenty-one B. sixty-five C. seventy D. thirty | B. sixty-five |
| TRICARE Prime is available to those eligible within __________ miles of a Primary Care Manager. A. 200 B. 100 C. 50 D. 80 | B. 100 |
| A person enrolled in CHAMPVA is responsible for __________ percent of covered charges. A. 25 B. 60 C. 50 D. 20 | A. 25 |
| The TRICARE health care program is a covered entity and subject to privacy rules under A. NAS. B. CHAMPVA. C. TCS. D. HIPAA. | D. HIPAA |
| Nonparticipating TRICARE providers cannot bill for more than __________ percent of allowable charges. A. 100 B. 50 C. 80 D. 115 | D. 115 |
| Active-duty service members are automatically enrolled in A. TRICARE For Life. B. TRICARE Prime. C. CHAMPUS. D. TRICARE Select. | B. TRICARE Prime |
| For individuals enrolled in TRICARE For Life, the primary payer is A. CHAMPVA. B. Medicare. C. a supplementary plan. D. TRICARE. | B. Medicare |
| Decisions about an individual's eligibility for TRICARE are made by the A. provider. B. Defense Enrollment Eligibility Reporting System. C. branch of military service. D. military treatment facility. | C. branch of military service |
| Place where medical care is provided to members of the military service and their families | Military Treatment Facility (MTF) |
| Amount of provider charges for which the patient is responsible | Cost-share |
| Department of Defense health insurance plan for military personnel and their families | TRICARE |
| Geographic area designated to ensure medical readiness for active-duty members | Prime Service Area |
| Fee-for-service military health plan | TRICARE Select |
| Government database containing information about patient eligibility for TRICARE | Defense Enrollment Eligibility Reporting System (DEERS) |
| Managed care plan that provides most services at military treatment facilities | TRICARE Prime |
| Annual limit on total medical expenses an individual or family may pay in one year | Catastrophic Cap |
| Department of Defense health insurance plan for military personnel and their families that was replaced in 1998 | CHAMPUS |
| provider who coordinates and manages a patient's medical care under a managed care plan | Primary Care Manager (PCM) |
| Program for individuals age 65 and older who are eligible for both Medicare and TRICARE; allows care at military treatment facilities | TRICARE For Life |
| Government health insurance program for families of veterans with 100 percent service-related disabilities | CHAMPVA |
| Uniformed services member whose status makes family members eligible for TRICARE coverage | Sponsor |
| Maximum amount TRICARE will pay for a covered service | CHAMPUS Maximum Allowable Charge (CMAC) |
| Provider certified by TRICARE to furnish covered services | Authorized Provider |
| Authorized provider who contracts with TRICARE and accepts negotiated rates | Network Provider |
| Provider who does not participate in the TRICARE network | Nonparticipating Provider |
| Identification card issued to eligible CHAMPVA beneficiaries | CHAMPVA Authorization Card |
| TRICARE regional administration area serving the eastern United States | TRICARE East |
| TRICARE regional administration area serving the western United States | TRICARE West |
| TRICARE region serving beneficiaries outside the United States | International Region |
| Agency responsible for TRICARE fraud and abuse oversight | Program Integrity Office |
| Form used to submit TRICARE claims for services from nonparticipating providers | DD Form 2642 |
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